The Impact of Staffing Shortages in Senior Care, and Strategies to Improve Recruitment and Retention
Marcy A. Metzgar
In 2023, LeadingAge (a community of more than 5,000 nonprofit aging services providers and other mission-driven organizations) found that 92 percent of its nursing home provider members and 70 percent of assisted living providers reported a significant or severe workforce shortage. Additionally, 64 percent noted no improvement in staffing shortages in the past year.1
In 2024, an American Health Care Association (AHCA) survey of 441 nursing homes revealed that two-thirds of nursing homes reported that ongoing staffing shortages may require them to close.2 Nearly half of them have had to turn some residents away, yet more than half of them maintain a waiting list for new residents. Seven of 10 nursing homes report to have fewer employees than before COVID-19.3 To manage these challenges, 97 percent of these organizations have asked staff members to work overtime or extra shifts; 73 percent have hired temporary staff members; 46 percent have limited new admissions; and 19 percent have closed a wing, unit, or floor.4
These sobering statistics reveal the critical state of employment in the senior care field. Staffing shortages, which were highlighted and exacerbated by COVID-19, are still very much prevalent. They are often a cause for burnout, turnover, unsafe staff-to-resident ratios, dangerous working conditions, and higher workloads and more overtime hours.5 Staff members have reported leaving their jobs because they experienced burnout, worked long hours, received poor pay and benefits, had limited advancement opportunities, and felt a lack of respect.6
Although nearly every nursing home in the United States is hiring, many of these organizations find recruiting difficult, and it takes months for most to hire qualified employees.7
Federal Staffing Requirements for Nursing Homes
Since staffing shortages in nursing homes can compromise resident safety and lower care quality, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), issued a proposed rule in September 2023 aimed to create comprehensive staffing requirements for nursing homes, including the introduction of national minimum nurse staffing standards.8
According to the AHCA survey, most nursing homes are concerned about meeting the proposed federal staffing mandate, which would require them to have a registered nurse (RN) on staff 24 hours per day, 7 days per week. (Current law requires nursing homes to have an RN on duty for 8 consecutive hours per day, 7 days a week. They also must have a licensed nurse — either an RN or licensed practical nurse — on duty 24 hours per day).9
The new rule would also require nursing homes to provide at least 3 hours of direct care per resident, per day, including at least 33 minutes from a registered nurse. A nursing home would need about 10 nurse aides per each 8-hour shift in a facility with 100 residents.10
The rule was finalized on April 22, 2024, and implementation of the regulations will occur in phases over several years.11
Strategies to Recruit, Educate, and Retain Staff Members
With changes in federal staffing requirements as well as the ever-increasing demand for healthcare workers, it remains challenging for senior care organizations to recruit new staff. Thus, it is imperative that senior care organizations commit to recruiting, educating, and retaining their nurses and other staff. Below are some strategies to help guide these efforts:
- Develop comprehensive onboarding and orientation programs, or review existing programs to determine areas for improvement.
- Integrate staff between care levels to facilitate employee collaboration and empowerment.
- Designate lighter workloads for new nurses and then add duties over time.
- Assign mentors as part of a mentorship program to foster a team culture and provide feedback to staff members.
- Have flexibility in scheduling options, such as staggering shifts where organizational tasks can be accomplished while staff members are given time to address personal and family needs (promoting positive work–life balance).
- Offer continuing education and other career growth opportunities to staff members.
- Initiate an incentive program to recognize and reward staff members who go above and beyond in caring for residents and assisting the organization to further its goals.
- Promote staff members and provide advancement opportunities.12
Some longer-term approaches may include:
- Reexamining and enhancing the organization’s benefits package to make it more appealing to attract staff members
- Using alternative scheduling and care models
- Creating nurse retention programs
- Partnering with local nursing schools and providing internships/apprentice programs for their students
- Designing respectful and purposeful roles for aging frontline healthcare workers so they can transition into a position that serves a social purpose in the organization13
Having a highly effective director of nursing (DON) championing these staff-retention efforts is integral to success, team building, and morale. The DON should value staff input, encourage skill building and leadership efforts among the staff, and hold staff accountable for high-quality performance and care delivery. All employees at the organization should feel that they are part of a highly skilled and recognized team. The increased focus on team building, communication, and respect will reinforce a positive culture and support staff recruitment and retention at the organization.
Endnotes
1 LeadingAge. (2023). LeadingAge workforce informal snap poll: Toplines. Retrieved from https://leadingage.org/wp-content/uploads/2023/03/Workforce-Snap-Poll-Toplines-2023-1.pdf
2 American Health Care Association. (2024, March). State of the nursing home sector: Survey of 441 nursing home providers highlights persistent staffing and economic crisis. Retrieved from www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/AHCA%20State%20of%20the%20Sector%202024.pdf
3 Ibid.
4 Ibid.
5 Munday, R. (2023, July 6). Chronic understaffing in nursing homes and the impacts on healthcare. The Nurse Journal. Retrieved from https://nursejournal.org/articles/chronic-understaffing-in-nursing-homes/
6 Paulin, E. (2022, June 9). Inside the 'staffing' apocalypse devastating U.S. nursing homes. AARP. Retrieved from www.aarp.org/caregiving/health/info-2022/labor-shortage-nursing-homes.html
7 American Health Care Association, State of the nursing home sector: Survey of 441 nursing home providers highlights persistent staffing and economic crisis.
8 The White House. (2023, September). Fact sheet: Biden-Harris administration takes steps to crack down on nursing homes that endanger resident safety. Retrieved from www.whitehouse.gov/briefing-room/statements-releases/2023/09/01/fact-sheet-biden-harris-administration-takes-steps-to-crack-down-on-nursing-homes-that-endanger-resident-safety/; Burns, A., Chidambaram, P., Neuman, T., & Rudowitz, R. (2023, September 22 [last updated]). What share of nursing facilities might meet proposed new requirements for nursing staff hours? Kaiser Family Foundation. Retrieved from www.kff.org/medicaid/issue-brief/what-share-of-nursing-facilities-might-meet-proposed-new-requirements-for-nursing-staff-hours/
9 Medicare.gov. (n.d.). Staffing for nursing homes. Retrieved from www.medicare.gov/care-compare/resources/nursing-home/staffing
10 The White House, Fact sheet: Biden-Harris administration takes steps to crack down on nursing homes that endanger resident safety.
11 Centers for Medicare & Medicaid Services, Department of Health and Human Services. (2024). Medicare and Medicaid Programs; Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting. Retrieved from https://public-inspection.federalregister.gov/2024-08273.pdf
12 Fordyce, L. (2019, August 14). How to attract and retain nurses in senior care. OnShift. Retrieved from www.onshift.com/resources/blog/how-to-attract-retain-nurses-in-senior-care; Hyde, T. (2024, January 15 [last updated]). 9 effective strategies to overcome the nurse staffing shortage. LG Resources. Retrieved from https://lgresources.com/blog/effective-strategies-to-overcome-nurse-staffing-shortage
13 Freeman, G. (2022, September 1). Staffing shortages could increase liability risks. Relias Media. Retrieved from www.reliasmedia.com/articles/staffing-shortages-could-increase-liability-risks; Cianci, N. (2023, February 13). How to tap the aging labor pool to attract frontline workers. American Health Care Association and National Center for Assisted Living. Retrieved from www.ahcancal.org/News-and-Communications/Blog/Pages/How-to-Tap-the-Aging-Labor-Pool-to-Attract-Frontline-Workers-.aspx
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